Frequently Asked Questions

Medical Care Issues

Georgia employers are supposed to have a panel of six doctors posted and one of them must be an orthopedic surgeon. You select a doctor and he or she becomes the authorized treating physician and provides treatment at the employer’s expense. If you see your own doctor, without authorization from the employer or their insurance carrier, they usually do not have to pay for the treatment. In an emergency situation prior authorization generally will not be required.

In Georgia, you have a right to an independent medical examination, to be paid for by the Employer/Insurer, but only one time and within 120 days of receiving any disability benefits. You may always seek a second opinion at your own expense, of course.

This is probably the most frustrating aspect of the workers’ compensation system for the doctors and for the injured employee. In Georgia, once an authorized treating physician is selected, the insurance company is supposed to pay for all reasonable treatment, but the doctors generally want to get authorization from the adjuster before scheduling appointments, tests, therapy, surgery, and so forth so they can be assured that they will be paid. This often results in delay.

If you have the money, you can always pay for a prescription yourself, provided it is written by the authorized treating physician, and then seek reimbursement from the insurance company. Of course, you may not be able to afford to pay for your prescription and then wait on reimbursement. Frequently, the adjuster will authorize a pharmacy to fill your prescriptions, but only if written by your authorized treating physician. And, insurance companies often contract with other vendors to review and monitor the prescriptions being filled. If a request for a new or different prescription is submitted, sometimes there is a delay while the medical records are obtained and the reason for prescribing the medicine is reviewed.

First, make sure that the bills have been properly submitted to the workers’ compensation insurance company. Insurance companies will not pay until they have documentation as to what the bill was for, that it was related to your work injury, and that it was either authorized or due to an emergency. Do not allow the employer or a medical provider to submit bills to your group health insurance provider. Most group plans (such as Blue Cross Blue Shield, for example) contain an exclusion for work related medical expenses. If the workers’ compensation carrier will not pay valid authorized or emergency medical expenses, we can file a motion with the Georgia State Board of Worker’s Compensation and try to get an order compelling payment.

If you are eligible for Medicare benefits, or will become eligible for Medicare within 30 months, settlement of future medical care becomes much more complicated. Medicare does not want employers or workers compensation insurance companies to dump their obligations for future medical expenses onto the Federal government. So, if settlement of future medical care is proposed and you are eligible for Medicare, a certain amount of the settlement money must be “set-aside” in a separate account to be used only for those medical expenses that would otherwise be paid by the workers’ compensation insurer. The account is called a Medicare Set-Aside account and is commonly referred to as a MSA. Only after the MSA funds have been properly spent on medical care will Medicare assume any responsibility for payment of your work related medical expenses. The MSA is designed to protect your right to Medicare benefits, and to protect the employer and insurer from being sued by Medicare for not paying for your future medical care.

Disability Issues

You are entitled to two-thirds of your average weekly wage, subject to a maximum limit of $575.00 per week for injuries occurring on or after July 1, 2016. For injuries occurring between July 1, 2013 and June 30, 2016, the maximum benefit is $525.00 per week. Before July 1, 2013, the maximum rate was $500.00 per week.

After an injury occurs, there is a one week waiting period before any disability benefits are due, so you get nothing for the first week off work. However, if the disability continues for at least 21 days, then the employer and their insurance carrier do have to make up and pay the first week’s benefits retroactively.

This is the most frequently asked question we get! Insurance companies are notorious for not paying on time. Unfortunately, they can legally run about two weeks behind on payment. In a Georgia case, benefits are due 21 days after the employer has knowledge of the injury and benefits are to be paid weekly thereafter. The law provides for an automatic 15% penalty if disability benefits are not paid when due.

Return to Work Issues

It depends. Of course, we hope that as a valuable employee with knowledge and skills, your employer will be anxious to have you back and will hold your job for you as long as possible. The workers’ compensation laws in Georgia do not require your employer to hold your job for you after an injury. However, your employer and their insurance company can frequently save money on the claim by putting you back to work when you are released by your doctor, which gives them some financial incentive to try to get you back to work. In Georgia, temporary benefits can continue for nearly eight years (400 weeks) if the employer does not put you back to work, so finding a job for you can save their insurance company a lot of money. And, the Federal Family & Medical Leave Act (FMLA) may apply in certain situations, and require the employer to restore you to your former position, or an equivalent position.

If you are released to return to work with certain restrictions (light duty), generally your employer has the option of offering a job within those restrictions or continuing to pay disability benefits. If you have to return to work at a job that pays less money, you may be eligible for temporary partial disability (TPD) benefits to make up for some of the difference between what you were earning before and what you are now earning on the light duty job. And, some benefits for permanent disability may be awarded even after you return to work, if you have permanent impairment.

General Questions

You can be fired at will in Georgia except for reasons prohibited under state or Federal law, such as race, color, sex, national origin, age or disability. An employer can almost always find a pretense for firing an employee, such as being late for work or for violating a safety rule, etc. However, there are financial incentives that usually discourage responsible employers from firing employees after an injury on the job, as discussed above.

Generally you cannot collect both unemployment benefits and disability benefits under workers’ compensation. You must be ready, willing and able to work to qualify for unemployment benefits. If there is a dispute over your injury on the job, or if the workers’ compensation benefits are delayed for some reason, and you are able to do light duty work, you can apply for unemployment benefits to help you get by, as long as you are careful to state on the application that you are willing to work within your restrictions.

No. Workers’ compensation is a no-fault system that provides benefits regardless of who caused the injury. Accidents on the job happen for many reasons. Sometimes a co-worker is careless, sometimes the employer furnishes defective equipment or working conditions are unsafe, and sometimes the injured person makes a mistake. Even if the employee is careless, causes an accident and hurt himself, he or she still gets workers’ compensation benefits. The trade-off for such a system is to prohibit the employee from suing the employer for anything other than workers’ compensation benefits. If the injury was due to the fault of someone other than the employee, a co-worker or the employer, however, the employee may be able to bring a lawsuit against the negligent party for medical expenses, lost earnings and pain and suffering. For instance, if the employee is injured in a wreck out on the highway while on the job, he/she could collect workers’ compensation benefits and still sue the “at fault” driver for all his/her damages. See Construction & Industrial Accidents. And Georgia, the Employer/Insurer would have a lien or subrogation claim on the proceeds, but only to the extent of benefits paid and provided the employee is fully compensated which is a variation of the made whole rule.

SUMMARY OF BENEFITS: GEORGIA WORKERS’ COMPENSATION LAW

Income Benefits

Disability benefits are 2/3’s of the average weekly wage, subject to a maximum limit of $575.00 per week for injuries occurring on or after July 1, 2016. For injuries occurring between July 1, 2013 and June 30, 2016, the maximum benefit is $525.00 per week. Before July 1, 2013, the maximum rate was $500.00 per week. The waiting period after an injury is 7 days; retroactive after 21 days of disability. Income benefits are due on the 21st day after the employer has knowledge of the injury. Temporary total disability (TTD) benefits continue as long as the employee remains disabled, up to 400 weeks from the date of injury. However, after release to light duty work, if employment is not provided by employer, the weekly disability check will be reduced to the temporary partial rate (TPD), not to exceed $383.00 for injuries occurring after July 1, 2016, ($350 per week (for injuries occurring between July 1 2013 and June 30, 2016), after 52 consecutive, or 78 aggregate, weeks on TTD. TPD benefits are limited to 350 weeks from the date of the accident. (No time limit in catastrophic injury cases) Benefits not paid on time must be increased by 15%, and benefits not paid on time after an award must be increased by 20%. Death benefits for dependents are limited to 400 weeks, generally, except that a surviving spouse can receive benefits until age 65, or for 400 weeks, whichever is greater (maximum of $230,000.00 for sole surviving spouse).

Medical Benefits

Generally, the Employer must furnish a panel of 6 physicians, one of whom must be an orthopedic surgeon, although other options for a conformed panel or managed care may be acceptable. 100% of necessary medical expenses incurred under the direction of an authorized treating physician are covered. Medical expenses include the employee’s travel to and from health care providers. The Board can order a change of physicians, or the employee can make one change to another physician on the panel, without authorization from the Board. The Employee is also entitled to one examination by a doctor of his or her choice, at the Employer’s expense, within 120 days of receipt of any income benefits. For injuries occurring on or after July 1, 2013, medical benefits are limited to 400 weeks from the date of injury, except in catastrophic injury cases. For injuries occurring before July 1, 2013, lifetime medical care for the injury is available.

Catastrophic Injuries

In cases involving spinal cord injury; amputation of an arm, a hand, a foot, or a leg; severe brain or closed head injury; second or third degree burns over 25 percent of the body or third degree burns to 5 percent or more of the face or hands; total or industrial blindness; or any other injury of a nature and severity that prevents the employee from being able to perform his or her prior work and any work available in substantial numbers within the national economy for which such employee is otherwise qualified (the same definition as for Social Security disability), the injury is considered to be catastrophic, and the employee is entitled to extended disability benefits, as well as lifetime medical care. Disability benefits are payable for life, but can be terminated after a hearing after the employee reaches the age of full retirement benefits for Social Security purposes (usually 67).

Rehabilitation

Mandatory only in catastrophic injury cases. Nurse Case Managers are not permitted to have direct contact with employee except in catastrophic injury cases, or by consent.

Coverage

Compulsory as to all employers of 3 or more, including State and local governments. Coverage is elective as to partners, sole proprietors or farm employers.

Notice

The employer is entitled to notice of an injury on-the-job, and until such notice is given, the employer is not responsible for any benefits. Notice must be given within 30 days.

Grounds For Denial

Compensation is not allowed for willful misconduct or injury due to intoxication by alcohol or drugs. Compensation can be denied for an unjustified refusal to submit to a drug test.

Administration & Hearings

The system administered by the State Board of Workers’ Compensation. Cases are supposed to be scheduled within 90 days of a hearing request, and are tried by an administrative law judge. The ALJ conducts hearings on the record, under the rules of evidence. Medical reports and records are generally admissible in lieu of medical depositions. Appeals go to the Appellate Division of the Board (the 3 directors of the Board), then to superior court, and then to the Court of Appeals.